Enrollment & Fee Verification Form

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Raising Riley

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Child Care Enrollment and Fee Verification Form

This form is to be completed by the director of the child care center or the child care provider and returned with the completed application.

Provider Information

Note: Providers must have permanent license and be in good standing with KDHE.

Do you accept DCF funds? *

Yes

Do you check e-mail regularly? *

Yes

Enrollment Information (via provider)

Is child enrolled in full-time care? *

Yes

Tuition Charged *

Monthly

Weekly

Child Care Center or Family Child Care Provider Responsibilities

This completed page must accompany each scholarship application

Be a licensed child care provider or center

RR regularly checks the KDHE Child Care Licensing Portal for survey findings,complaints and notices of non-compliance. Partners with the RR scholarship program are expected to meet high standards for the health and safety of children in care. These standards may exceed licensing standards. If RR deems a facility’s operations reflect issues regarding health and safety or if there are non-compliance notices on the CCL portal then a suspension from this partnership could result. Raising Riley will suspend this partnership for the length of time that a notice of non-compliance for health and safety issues remains on the KDHE CCL portal.

Located in Manhattan/Riley County

Provider must complete and submit Child Care Scholarship Request for Payment form monthly for payment. *A Welcome to Raising Riley visit will be made by RR Facilitator once scholarship is awarded. The facilitator will outline how to submit for your monthly reimbursement. Reimbursement will be paid directly to provider

Allow a Raising Riley facilitator to visit home /center classroom for an observation twice a year.

RR Provioders must notify Raising Riley of any change in scholarship family or employment status, additional tuition assistance, the number of hours a child is in care, or intent to exit this child. RR Scholarships will not be used to "hold" spots for children in care.

I certify that the information listed above is accurate to the best of my knowledge and that this child is enrolled in care.

Provider Signature

Thanks for submitting!

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